Prevalence and Factors of Intensive Care Unit Conflicts

The Conflicus Study

Élie Azoulay1, Jean-Francxois Timsit2, Charles L. Sprung3, Marcio Soares4, Kateřina Rusinová5, Ariane Lafabrie1,
Ricardo Abizanda6, Mia Svantesson7, Francesca Rubulotta8, Bara Ricou9, Dominique Benoit10, Daren Heyland11,
Gavin Joynt12, Adrien Franc xais2, Paulo Azeivedo-Maia13, Radoslaw Owczuk14, Julie Benbenishty3, Michael de Vita15,
Andreas Valentin , Akos Ksomos17, Simon Cohen18, Lidija Kompan19, Kwok Ho20, Fekri Abroug21,
16

Anne Kaarlola22, Herwig Gerlach23, Theodoros Kyprianou24, Andrej Michalsen25, Sylvie Chevret26, and
Benoı̂t Schlemmer1, for the Conflicus Study Investigators and for the Ethics Section of the European Society
of Intensive Care Medicine*
1
AP-HP, Hôpital Saint-Louis, Medical ICU, University Paris-7 Paris-Diderot, UFR de Médecine, Paris, France; 2INSERM U823, Hopital Michallon, CHU
de Grenoble, Grenoble, France; 3Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem,
Israel; 4Intensive Care Unit, Instituto Nacional de Câncer, Rio de Janeiro, Brazil; 5Department of Anesthesiology and Critical Care Medicine, Medical
ICU, Prague University Hospital, Prague, Czech Republic; 6Servei de Medicina Intensiva, Hospital Universitario Asociado General de Castellón,
Castellón, Spain; 7Centre for Health Care Sciences, Orebro University Hospital, Orebro, Sweden; 8Policlinico University Hospital Catania, Italy;
9
Department of Intensive Care, Geneva University Hospitals and University of Geneva, Geneva, Switzerland; 10Department of Intensive Care
Medicine, Ghent University Hospital, De Pintelaan Ghent, Belgium; 11Department of Medicine, Queen’s University, Kingston, Ontario, Canada;
12
Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong; 13Department
of Anesthesia and Intensive Care, Hospital de S. João, Porto, Portugal; 14Department of Anaesthesiology and Intensive Therapy, Medical University of
Gdansk, Gdansk, Poland; 15University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; 16General and Medical Intensive Care Unit, II, Medical
Department, KA Rudolfsftiftung, Juchgasse, Vienna, Austria; 17Semmelweis University, Surgical Intensive Care Unit, Budapest, Hungary;
18
Department of Medicine, University College London, London, United Kingdom; 19Clinical Centre Ljubljana, University of Ljubljana, Ljubljana,
Slovenia; 20Intensive Care Unit, Royal Perth Hospital, Perth, Australia; 21Intensive Care Unit, CHU Fatouma Bourguiba, Monastir, Tunisia;
22
Department of Anaesthesia and Intensive Care Medicine, Helsinki University Central Hospital, Helsinki, Finland; 23Department of Anesthesia,
Intensive Care Medicine, and Pain Management, Vivantes Klinikum Neukölln, Berlin, Germany; 24Department of Computer Science, University of
Cyprus, Nicosia, Cyprus; 25Department of Anesthesiology and Critical Care Medicine, HELIOS Spital, Überlingen/See, Germany; 26Biostatistical
Department, U717 INSERM, AP-HP, Paris 7 University, Saint-Louis Hospital, Paris, France

Rationale: Many sources of conflict exist in intensive care units (ICUs).

Few studies recorded the prevalence, characteristics, and risk factors
for conflicts in ICUs.
Objectives: To record the prevalence, characteristics, and risk factors
for conflicts in ICUs.
Methods: One-day cross-sectional survey of ICU clinicians. Data on
perceived conflicts in the week before the survey day were obtained
from 7,498 ICU staff members (323 ICUs in 24 countries).
Measurements and Main Results: Conflicts were perceived by 5,268
(71.6%) respondents. Nurse–physician conflicts were the most
common (32.6%), followed by conflicts among nurses (27.3%) and
staff-relative conflicts (26.6%). The most common conflict-causing
behaviors were personal animosity, mistrust, and communication
gaps. During end-of-life care, the main sources of perceived conflict
were lack of psychological support, absence of staff meetings, and
problems with the decision-making process. Conflicts perceived as
severe were reported by 3,974 (53%) respondents. Job strain was
significantly associated with perceiving conflicts and with greater
severity of perceived conflicts. Multivariate analysis identified 15
factors associated with perceived conflicts, of which 6 were potential
targets for future intervention: staff working more than 40 h/wk,
(Received in original form November 17, 2008; accepted in final form July 27, 2009)
Supported by a grant from the European Society of Critical Care Medicine
(ECCRN Established Investigator Award 2007).
* A complete listing of the Conflicus study investigators can be found in the
online supplement.
Correspondence and requests for reprints should be addressed to Élie Azoulay,
M.D., Ph.D., AP-HP, Hôpital Saint-Louis, Medical ICU, University Paris-7 Paris-
Diderot, UFR de Médecine, 1 avenue Claude Vellefaux, 75010 Paris, France.
E-mail: elie.azoulay@sls.ap-hop-paris.fr
This article has an online supplement, which is accessible from this issue’s table of
contents at www.atsjournals.org
Am J Respir Crit Care Med Vol 180. pp 853–860, 2009
Originally Published in Press as DOI: 10.1164/rccm.200810-1614OC on July 30, 2009
Internet address: www.atsjournals.org
AT A GLANCE COMMENTARY
Scientific Knowledge on the Subject
Conflicts in the intensive care unit create obstacles to good
communication and decision making and may threaten the
quality of care. However, no study has evaluated the
prevalence of, or the factors associated with, ICU conflicts.
What This Study Adds to the Field
Up to 70% of intensivists reported conflicts. These conflicts
are perceived as severe in more than half the cases, and they
are associated with increased job strain.
more than 15 ICU beds, caring for dying patients or providing pre-
and postmortem care within the last week, symptom control not
ensured jointly by physicians and nurses, and no routine unit-level
meetings.
Conclusions: Over 70% of ICU workers reported perceived conflicts,
which were often considered severe and were significantly associ-
ated with job strain. Workload, inadequate communication, and
end-of-life care emerged as important potential targets for improve-
ment.
Keywords: end-of-life; caregivers; nurses; family members; burnout
Intensive care units (ICUs) are probably the most stressful places
in hospitals (1–3). To restore organ function and overall health in
patients with acute life-threatening illnesses, ICU workers must
often unravel a complex web of causative factors while making
multiple treatment decisions in rapid succession (4). At the same
time, they must provide clear and honest information to the patient
or family, who are often struggling with emotional distress (5, 6).
There may be insufficient time and energy available to identify and
854 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 180 2009

work on sources of conflict within the ICU staff and with patients TABLE 1. INTENSIVE CARE UNIT CHARACTERISTICS
or families. Furthermore, when death becomes inevitable, conflicts
Number (%) or Median
related to end-of-life decisions (7) may occur within the ICU team, Variable (Interquartile Ranges)
with consultants, and with the family (8–11).
Despite evidence that conflicts are common and harmful in Public hospitals 255 (81.5)
Number of hospital beds 500 (264–845)
the ICU (12, 13), no large study has recorded their prevalence,
Hospitals with more than 5% of paying patients 64 (20.4)
characteristics, and risk factors. In a study in patients with pro- University and university-affiliated hospitals 170 (54.3)
longed ICU stays, Studdert and colleagues identified conflicts Type of ICU
for 31.8% of patients (14). Other studies focused on conflicts at Medical 39 (12.5)
the end of life. Although interviews of ICU directors suggested Surgical 25 (8)
a low rate of conflicts (15), family members reported conflicts Medical-surgical 223 (71.2)
Trauma 5 (1.6)
for up to 78% of patients in whom the appropriateness of con-
Cardiac 7 (2.2)
tinued life-supporting treatment was in doubt (16). Most of the Other 14 (4.5)
conflicts occurred either between families and ICU staff mem- Closed ICUs (as defined by the investigators) 185 (59.1)
bers (8) or within the ICU team (17). Conflicts not only create Number of ICU beds 12 (8–18)
distress, but also potentially affect quality of care (2, 18, 19). ICU mortality in 2005 16 (9.5–22)
Thus, ICU conflicts have been shown to be strongly associated Presence of a senior physician 24 h/d 235 (75.1)
Number of nurses per ICU 25 (14–40)
with burnout syndrome in nurses and physicians (12, 13). Further-
Number of physicians per ICU 6 (4–10)
more, the rate of conflicts has been used to assess several in- Availability of an ethics consultant 142 (45.4)
terventions, such as proactive communication strategies (20) and Availability of a psychologist 177 (56.5)
ethics consultations (21). Finally, an intervention specifically Routine recording of ICU conflicts 52 (16.6)
designed to decrease conflicts surrounding decision-making in Relevance of the topic of ICU 50 (30–80)
seven ICUs was evaluated (22). The intervention facilitated de- conflicts, scored from 0–100
liberative decision making without improving patient or surrogate Definition of abbreviation: ICU 5 intensive care unit.
satisfaction.
The objective of this study was to examine the prevalence,
characteristics, and factors of ICU conflicts reported by ICU
obtained by adding the control and social-support subscores, then
staff that occurred in the week before the survey day, in several
subtracting the demand subscore ([(social support 1 control) 2 demand]).
parts of the world. Because we sought to assess the burden on Therefore, the lower the job demand score, the higher the score and lower
ICU staff members, we focused on perceived conflicts without the job strain. Also, the higher the social support or the job control scores,
trying to achieve objective standardization of responses. the higher the score and the lower the job strain. Overall, the higher the
total score, the lower the job strain.
METHODS Selection of Participating Countries and Centers
Study Design The ESICM Ethics section members (240 intensivists and nurses) were
invited to participate in the study. Among those who agreed, 26 were
In 2006, the ethics section of the European Society of Intensive Care national coordinators who represented 397 ICUs in 29 countries
Medicine (ESICM) designed a 1-day cross-sectional study on conflicts (Figure 1). Each national coordinator was asked to provide comments
in the ICU. A questionnaire designed to collect data on ICU conflicts on the questionnaire; to translate the questionnaire into that country’s
(see the online supplement) was prepared by the ESICM Ethics sec- language and to have the translated version validated by a national
tion. The questionnaire was to be completed by all staff members coordinator of another country having the same language or by another
working in each participating ICU on December 7, 2006. investigator from the same country, helped by physicians and nurses
working in the same ICU; to invite adult ICUs in the national society to
Development of the Questionnaire
participate in the study; and to obtain approval from the ethics committee
A panel composed of the ESICM members (physicians and nurses) for each ICU.
used a five-step modified Delphi approach to develop a consensus In each ICU, one physician or nurse was the local investigator. Each
about definitions of perceived ICU conflicts and the information to be local investigator received a copy of the research project and translated
collected during the study (Appendix 1). Suggestions made during questionnaire and organized a local information meeting for ICU staff
the coordinators’ meeting at the annual ESICM conference were in- members in the relevant ICU 2 to 4 weeks before the study. Local
corporated. Questionnaire validation conducted in three centers led to investigators completed a form on ICU characteristics. Each local
changes in the order of items. Conflict was defined according to Studdert investigator recorded the number of intensivists scheduled to work in
and colleagues, with modifications (14), as: ‘‘Dispute, disagreement, the ICU on the study day (December 7, 2006). As 9,274 clinicians in the
incompatibility, opposition, or difference of opinion involving more than 397 participating ICUs were scheduled to work on the study day, 9,274
one individual and related to the patient’s management or to interper- questionnaires were sent to each local investigators.
sonal conflict.’’ ICU conflicts were described according to three cate-
gories of perceived characteristics: parties involved in the conflict, source Approval by Local or National Ethics Committees
of the conflict, and clinical impact and severity of the conflict. and Confidentiality
Ethics committee approval according to local legislation was manda-
Other Collected Variables tory for study participation. Failure to meet this requirement led to
The ICU and respondent characteristics reported in Table 1 were exclusion of six ICUs from the study.
collected. Three country characteristics taken from the World Health Participating ICU physician and nurse staff members completed an
Organization website (http://www.who.int/research/en/) were recorded: anonymous questionnaire on perceived ICU conflicts over the last
number of physicians per 1,000 population, percentage of urban pop- 7 days in their ICU.
ulation in the country, and government expenditure on health. Because
conflicts in the ICU may be associated with job strain, respondents Audit of the Database
were asked to complete a 12-item scale derived from the Job Content Data entry was centralized and was performed by two technicians who
Questionnaire (http://www.workhealth.org/strain/jsquest.html) (23). used a double-keyboarding procedure. Inconsistent data on ICU
This scale explores three domains (job demand, control, and social characteristics were corrected by national coordinators. No effort was
support) to measure the degree of job strain (24). The job strain score was made to obtain missing data. The job strain score was computed only
Azoulay, Timsit, Sprung et al.: Conflicts in the ICU
for those respondents who completed the 12-item scale (all but 574 of
the 7,358 respondents).
Statistical Analysis
Continuous variables were reported as medians (interquartile ranges)
and categorical variables as proportions. For between-group compar-
isons, we used the Wilcoxon rank-sum test for continuous variables and
either the Pearson chi-square test or Fisher exact test, as appropriate,
for categorical variables. Continuous variables were dichotomized
using medians as cut-off values.
The variables were organized into three tiers: country, ICU, and
respondent. To identify factors associated with reporting one or more
conflicts, we built a three-tiered hierarchical logistic mixed model using
the GLIMMIX procedure of the SAS software version 9.1 (SAS In-
stitute, Cary, NC). The effects of country-based and ICU-based variables
on the outcome (conflict[s] or no conflict) were included through both
fixed and random effects. Multilevel modeling takes into account the
hierarchical structure of the data, which may manifest as intraclass
correlations. To obtain a conservative estimate of the standard error,
a separate random-error term should be specified for each level of the
analysis (25). Therefore, to avoid overestimating the significance of risk
factors for reported conflicts, we took intraclass correlations into account,
and we specified a separate random-error term for each tier. Variables
potentially associated with reported conflicts that occurred were intro-
duced into the multivariate model and selected using a backward ap-
proach. The hierarchical model comprised three levels: country (level 3),
center (level 2), and respondent (level 1). All variables with P values less
than 0.10 by univariate analysis were introduced into the multivariate
model (Table 4). We did not correct for multiplicity of statistical tests. All
tests were two-sided. All statistical tests were performed using the SAS
software package, version 9.1.
RESULTS
We received 7,498 (81%) completed questionnaires from 323
(81%) ICUs in 24 (83%) countries (Figure 1). Table E1 in the
online supplement reports the number of participants in each
country. Among staff members working on the study day, 80%
participated in the study. The 140 questionnaires with no answers
855
Figure 1. Study flow chart.
to more than 12 items were excluded. Among the remaining 7,358
respondents, 2,090 (28%) reported no perceived conflicts within
the last week and 5,268 (72%) reported at least one perceived
conflict; 409 (5.5%) respondents reported more than one per-
ceived conflict. The prevalence of respondents reporting perceived
conflicts varied considerably (from 26 to 100%) across countries.
ICU characteristics are reported in Table 1. ICUs had a median
of 12 (interquartile range, 8–18) beds. The patient-to-nurse ratio
was 2 (1–3) and the patient-to-physician ratio was 5 (2.5–6). An
ethics consultant was available in 142 (45%) ICUs and a psychol-
ogist in 177 (56.5%) ICUs. Table 2 shows that about half the ICUs
held routine unit-level meetings at least weekly and that 55 (18%)
ICUs allowed unrestricted visitation. Decisions were routinely
shared with family members in one-third of participating ICUs.
Overall, nurses were involved in half the discussions and decisions
to forgo life support. Symptom control at the end of life was
ensured jointly by nurses and physicians in 65% of the ICUs.
Table 3 reports the characteristics of the respondents. Nurses
and nurse assistants contributed 59.5% of the respondents.
Table 3 and Figure 2 depict the characteristics of ICU con-
flicts. One-third of conflicts occurred between ICU staff and
patients or relatives and the remaining occurred within the ICU
team. To assess the pathogenesis of conflicts, we asked respon-
dents about sources of conflict and links to earlier events. The
main reported sources of conflict were general behaviors (Figure
2A) and end-of-life care (Figure 2B). Among general behaviors
perceived as causing conflicts, the most common were personal
animosity, mistrust, and poor communication within the ICU
team. The main perceived sources of conflict related to end-of-
life care were lack of psychological support, absence of unit-level
meetings, and problems with the decision-making process.
Furthermore, 1,874 (25%) respondents believed that the conflict
they reported was related to a previous conflict and 6,523 (87%)
anticipated that the same type of conflict would recur in their
ICU. Most respondents (5,248, (70%) believed that the reported
conflict could have been prevented.
856 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 180 2009

TABLE 2. INTENSIVE CARE UNIT ORGANIZATION TABLE 3. CHARACTERISTICS OF THE RESPONDENTS

Variable Number (%) Characteristics of the Number (%) or Median
Respondents (N 5 7,498) (Interquartile Ranges)
Nurse–physician interactions
Participation of ICU nurses in daily rounds 286 (91.4) Age 34 (28–42)
Participation of ICU nurses in clinical research 154 (49.2) Female sex 5,316 (70.9)
Regular unit-level meetings (at least one/wk) 153 (48.9) Religiosity (0 not religious to 5 very religious) 2 (0–3)
Availability of ICU working groups 216 (69) Born in the country in which the 6,425 (87.9)
Interactions with family members respondent works (7,310 answers)
Provision of a family information leaflet 203 (64.8) Graduated in the country in which the 6,520 (91.7)
24-h visitation policy 55 (17.6) respondent works (7,105 answers)
Recent extension of visiting hours 114 (36.4) Not married (7,105 answers) 2,874 (40.4)
Availability of a room for family information 235 (75.1) Number with children 4,041 (53.9)
Family members allowed to sleep in the ICU 72 (23) Job title in the ICU
Routine use of the shared decision-making model 104 (33.2) Nurse 3,300 (44)
Routine involvement of relatives in patient care, if desired 88 (28.1) Nursing assistant 1,161 (15.5)
Family information provided jointly by nurses and physicians 142 (45.4) Senior physician 595 (7.9)
Time slot dedicated specifically to family information each day 147 (47) Junior physician 521 (7)
End-of-life care (4 centers with missing values) Physiotherapist 359 (4.8)
Nurses involved in EOL discussions Consultant 320 (4.3)
Always or routinely 108 (35) Head nurse 273 (3.6)
Frequently 71 (23) ICU head 145 (1.9)
Rarely or never 130 (42) Other 529 (7)
Nurses involved in EOL decisions Unknown 295 (3.9)
Always or routinely 99 (32.1) Number of years spent working in the ICU 6 (2–12)
Frequently 75 (24.3) Hours worked per wk 40 (36–50)
Rarely or never 135 (43.6) Hours worked per shift 8 (8–12)
Routine information of relatives about EOL decisions Number of wk since last vacation 12 (5–17)
Always or routinely 233 (75.4) Received training in ethics and communication 3,197 (40.4)
Frequently 35 (11.3) Number of dying patients cared for over the last wk 1 (0–2)
Rarely or never 41 (13.3) Number of end-of-life decisions 0 (0–1)
Nurses present at family end-of-life meetings implemented over the last wk
Always or routinely 81 (26.2) Number of deaths over the last wk 0 (0–2)
Frequently 67 (21.7) Receiving antidepressant therapy 592 (8.1)
Rarely or never 161 (52.1) Job Strain Scale: total score* 5 (3–6)
Who implements EOL decisions Demand 1 (0–1)
Nurses alone 7 (2) Control 2 (1–3)
Physicians alone 144 (46.7) Social support 3 (2–4)
Both nurses and physicians 158 (51.3) Parties involved in conflicts among the 5,268
Who makes symptom-control decisions at the end of life respondents who reported at least one conflict
Nurses alone 2 (0.6) Physicians and nurses 1,719 (32.6)
Physicians alone 107 (34.6) ICU nurses 1,437 (27.3)
Both nurses and physicians 200 (64.7) ICU staff and family 1,402 (26.6)
Use of terminal extubation ICU physicians 1,312 (24.9)
Always or routinely 20 (6.5) ICU staff and consultants 1,075 (20.4)
Frequently 54 (17.5) ICU staff and patients 906 (17.2)
Rarely or never 235 (76) ICU staff and physiotherapists 882 (16.7)
Dying patients can be discharged to wards 162 (52.4)
Definition of abbreviation: ICU 5 intensive care unit.
Definition of abbreviations: EOL 5 end of life; ICU 5 intensive care unit. * The Job Strain Scale is a 12-item scale derived from the Job Content
Questionnaire (http://www.workhealth.org/strain/jsquest.html). This scale ex-
plores three domains (job demand, control, and social support) to measure the
To assess the magnitude of conflicts, the questionnaire in- degree of job strain. The total score is obtained by adding the control and social-
support subscores then subtracting the demand subscore. Higher scores indicate
cluded several response options: severe, dangerous, harmful,
less job strain.
counterproductive, and hurtful (to the respondent). Respondents
could select none, one, or several of these descriptors. Conflicts
were perceived as ‘‘severe’’ by 3,974 (53%) respondents, as
‘‘dangerous’’ by 3,899 (52%) respondents, and as ‘‘harmful’’ by survey. Informal debriefing and discussion was perceived to be
6,253 (83%) respondents. Several other findings suggested that the best means of resolving intrateam conflicts (80 and 84% of
the reported conflicts constituted substantial problems. Thus, the nurses and doctors, respectively). Compared with intrateam
job strain score was significantly lower (indicating more job conflicts, conflicts between staff and patients/relatives less often
strain) for respondents reporting at least one conflict, and job led to the intervention of a consultant (42.8 vs. 57.6%, P ,
strain scores were also lower when conflicts were described as 0.0001), face-to-face debriefing (75.9 vs. 84.8%, P , 0.0001), or
severe or dangerous (Figure 3). When interviewed about the intensified communication within the ICU team (84.1 vs. 76.6%,
effects of conflicts within the past 7 days on team cohesion, P , 0.0001). However, conflicts between staff and patients/
respondents reported that conflicts were harmful to relations relatives more often resulted in patient transfer to another ICU
within the ICU team in 92% of cases and to relations with or to a ward (13.5 vs. 7.5%, P , 0.0001), initiation of an ICU
consultants and families in 75% of cases. A possible harmful working group (48.3 vs. 42.7%, P 5 0.0004), limitation of
effect of conflicts within the past 7 days on quality of care was visiting hours for the relatives (39.1 vs. 25.9%, P , 0.0001),
reported by 70% of respondents, and 44% of respondents intensified communication with the relatives (80.6 vs. 67.1%,
reported a possible harmful effect on patient survival. P , 0.0001), or legal action (16.3 vs. 9.8%, P , 0.0001).
Several questionnaire items investigated conflict resolution. By multivariate analysis, 15 factors were associated with
Only 3,000 (40%) conflicts were resolved at the time of the conflicts within the past 7 days, including 6 factors potentially
Azoulay, Timsit, Sprung et al.: Conflicts in the ICU
amenable to improvement (Table 4). The country itself was not
independently associated with the prevalence of conflicts. The
nine factors that were not potential targets for improvement
were male sex of the respondent, age older than 34 years, being
a parent, specific training in ethical issues, being the head of
the ICU, being a junior physician, being a senior physician,
being a nurse, and lower government health expenditure. Doc-
tors were less likely to report conflicts than were other staff
members. Of the six independent factors that were potential
targets for improvement, four were associated with a higher
prevalence of conflicts, namely, working more than 40 hours per
week, having more than 15 beds in the ICU, caring for one or
more dying patients over the last week, and providing premortem
and postmortem care for at least one patient who died within the
last week. Two other factors were associated with fewer conflicts:
symptom control performed jointly by physicians and nurses
and routine unit-level meetings. A sensitivity analysis limited to
severe conflicts identified similar risk factors (data not shown).
DISCUSSION
In this large cross-sectional survey, we found that up to 70% of
ICU staff members reported ICU conflicts. More than 80% of
conflicts were perceived as more harmful than useful and half as
severe or dangerous. Conflicts were significantly associated with
job strain. Several factors associated with conflicts in this study
may be amenable to specific preventive strategies.
857
Figure 2. Sources of conflicts. (A) Sources of
behavior-related conflicts. (B) Sources of con-
flicts associated with end-of-life care.
This is the first large multicenter study on the incidence of
conflicts reported by ICU staff. Moreover, no published studies
report the prevalence of conflicts in acute care wards, emergency
departments, operating rooms, or clinics. Only three previous
studies investigated the prevalence of ICU conflicts, and they
focused chiefly on conflicts involving, or reported by, patients
and relatives. Conflicts occurred for nearly one-third of patients
with prolonged ICU stays (14), the main sources of team–family
conflicts being decisions about life-sustaining treatments and poor
communication. Although ICU directors reported few conflicts
(15), families and ICU physicians and nurses perceived conflicts for
up to 80% of patients requiring treatment-limitation decisions (8,
16). Among 48 family members of ICU patients who participated
in audiotaped interviews, 46% reported conflicts, most of which
were team–family conflicts stemming from perceived poor com-
munication or unprofessional behavior (8, 16). In a study involving
semi-structured interviews of physicians and nurses, conflicts were
reported for 78% of patients requiring treatment limitation (16).
The main sources of conflict were decisions about life-sustaining
treatment, communication, and pain control (16). These findings
prompted studies of ways to address and to prevent conflicts
surrounding ICU end-of-life care (9, 20, 21, 26).
This survey is the first study that provides information from
a large number of ICU staff members in several countries.
Moreover, respondents were given the opportunity to report all
perceived conflicts and risk factors, including intrateam conflicts
and conflicts unrelated to end-of-life care. A striking finding is
858 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 180
Figure 3. Impact of conflicts on job strain according to (A) perceived
severity or (B) dangerousness of conflicts. Lower demand and higher
control and social support lead to higher score and indicate less job
strain; therefore, the total score is obtained by adding the control and
social-support subscores then subtracting the demand subscore.
Higher total scores indicate less job strain. P value , 0.0001 for all
comparisons using the Kruskal-Wallis test between the level of severity
or danger (ranked from 0–5) and the Job Strain Score.
that intrateam disputes accounted for the majority of conflicts,
with only half the conflicts stemming from end-of-life care. In
agreement with previous findings, poor communication within
the ICU team, in general or during end-of-life care, was perceived
as a common source of conflict. This finding and previous data
support the usefulness of conflict-prevention strategies centered
on ICU staff members.
Among the variables significantly associated with conflicts in
our study, six may be amenable to change as part of conflict-
reduction strategies. Although the length of the workweek and
number of beds per ICU may seem difficult to change, previous
studies indicate that decreasing the patient-to-nurse ratio to mit-
igate the physical and emotional strain placed on nurses improves
patient safety, quality of care, and cost-effectiveness (12, 18, 19,
2009
27). Regarding the number of ICU beds, the apparent contradic-
tion between cost-effectiveness and the well-being of ICU
workers requires further investigation (28). A valid evaluation
would require integrating the cost of absenteeism, back pain, and
high nurse turnover related to job dissatisfaction, as well as costs
related to conflicts and to poor patient outcomes stemming from
ICU size. We found that conflicts were less likely to occur in ICUs
that held regular staff meetings. Previous studies indicate that
multidisciplinary unit-level conferences for debriefing staff mem-
bers are rarely held (29). Nurses have reported that it is difficult to
speak up, that disagreements are not appropriately resolved, and
that nurse input into decision making should be increased but is
not well received by physicians (30). Moreover, discrepancies
have been identified between nurses and physicians regarding the
quality of collaboration and communication (17). These discrep-
ancies were associated with suboptimal conflict resolution (29).
Unit-level meetings, with the head nurse and ICU director
rotating as facilitators, provide excellent opportunities for high-
lighting the valuable role played by nurses in the ICU, enhancing
respect and understanding within the ICU team and ensuring that
all team members send the same messages to patients and families
(31). During unit-level meetings, team members can express and
talk through their disagreements, identify and resolve sources of
hostility, share information about patients and families, and
communicate their uncertainties regarding medical decisions.
Well-led meetings may promote a sense that all members of the
team contribute equally to the chain of events that affects patient
outcomes, family outcomes, ICU worker burnout, and the oc-
currence of conflicts (32). Surprisingly, training in ethics was
associated with a higher rate of perceived conflicts. However, we
did not include training in ethics among factors amenable to
improvement, as we believe that selection bias occurred re-
garding this factor: ICU members who were more sensitive to
conflict were probably more likely to have sought specific training
in ethics and communication. Also, staff members with training in
ethics were perhaps asked to assist with cases generating conflict.
Three of the six variables amenable to potential preventive
strategies were related to end-of-life care. In previous studies,
most conflicts occurred during the care of dying patients (8, 14,
16). In our study, both end-of-life care and a higher number of
deaths were independently associated with conflicts. Therefore,
ensuring that the same physician or nurse is not in charge of
several dying patients at the same time might reduce conflicts.
In addition, although death of patients is the strongest risk factor
for burnout in ICU staff (13), improving communication to assist
the decision-making process increases job satisfaction (33, 34).
Explaining the principles of palliative care to families and having
physicians and nurses work together to evaluate pain, anxiety,
and other symptoms are simple means of decreasing conflicts
while significantly improving the quality of death. Although stud-
ies are needed to confirm these results, we believe that available
data are sufficiently convincing to warrant changes in clinical
practice. We suggest testing interventions designed to reduce con-
flicts, such as decreasing the number of working hours, holding
unit-level meetings at least once a week, and ensuring that each
ICU staff member is responsible for no more than one dying
patient at a time. Evaluation criteria should include patient outcomes
(safety, quality of care, and quality of death), family-related variables
(satisfaction, stress, and anxiety), and ICU staff-related variables
(satisfaction, burnout, conflicts, and absenteeism), as well as cost-
effectiveness criteria.
This study has several limitations. First, we defined conflicts
and selected questionnaire items based on the existing literature
and on suggestions from a panel of practicing ICU physicians and
nurses. The definition of conflict used in our study may be open to
criticism, and some of the types of reported conflicts may have
Azoulay, Timsit, Sprung et al.: Conflicts in the ICU 859

TABLE 4. FACTORS ASSOCIATED WITH INTENSIVE CARE UNIT CONFLICTS

(MULTIVARIATE HIERARCHICAL ANALYSIS)
Estimate Odds Ratio* 95% CI P Value

Intercept 3.0604
Respondent characteristics
Male sex 0.1871 1.21 1.05–1.40 0.0101
Older than 34 yr 20.1603 0.85 0.74–0.98 0.0236
At least one child 20.1414 0.87 0.75–1.00 0.0507
Works more than 40 h/wk 0.2561 1.29 1.11–1.50 0.0009
Training in ethics 0.1638 1.18 1.02–1.34 0.0089
Job title in ICU†
Doctor Reference 1 — 0.0005
Nurse 20.1858 0.83 0.69–1.00
Physiotherapist 20.4911 0.61 0.45–0.83
Other 20.4567 0.63 0.49–0.82
End-of-life care
Cared for at least one patient who died within the last wk 0.1546 1.17 1.02–1.34 0.0270
Involved in premortem and postmortem care of at least one 0.4248 1.53 1.33–1.76 ,1024
dying patient within the last wk
Symptom control in dying patients ensured jointly 20.2488 0.78 0.59–1.03 0.0753
by nurses and physicians
Center characteristics
Routine ICU unit-level meetings 20.2725 0.76 0.57–1.02 0.0666
More than 15 ICU beds 0.2522 1.29 0.97–1.70 0.0771
Country characteristics
Government health expenditure (as a percentage of total 20.0240 0.98 0.96–1.00 0.0363
government expenditure)
Covariance parameters Estimate Standard Error
Country 0.2906 0.1199
ICU 0.7595 0.0962

Definition of abbreviations: CI 5 confidence interval; ICU 5 intensive care unit.

* Higher odds ratios indicate factors associated with more conflicts.
†
The variable ‘‘job title’’ encompassed four groups: doctors (senior physicians, junior physicians, consultants, and ICU heads
who were physicians), nurses (nurses, nurse assistants, and ICU heads who were nurses), physiotherapists, and other. ‘‘Doctors’’
was the reference category.

limited relevance. However, our finding that 80% of reported
conflicts were perceived as severe or dangerous suggests that
conflicts were believed to be major problems. Also, we are not
able to tell how many of the respondents per ICU reported the
same conflict. Therefore, we cannot separate conflicts that staff
members experienced themselves from conflicts they perceived
in others. Second, we did not collect data on the culture in
each ICU, most notably how respondents would place their
ICU on a line from a hierarchical/paternalistic environment to
a democratic/equal-rights environment. However, if ICU culture
affects conflict occurrence, and if ICU culture reflects the overall
culture of the country where the ICU is located, one would expect
to see major differences in conflicts between countries. No such
differences were found in this study. Third, we were unable to
separate chronic conflicts from acute conflicts. Respondents were
perhaps more likely to focus on ongoing conflicts rather than on
conflicts that were resolved during the last week. Conflict severity
and resolution may vary according to time from the beginning of
the conflict, and occasional conflicts within a team that works well
together may have a different impact from conflicts within
a climate of simmering anger and resentment. Respondents were
asked to report conflicts that occurred within the last week. How-
ever, fewer than half the respondents reported that the conflict
was resolved at the time of the study, about 80% believed that the
same type of conflict was likely to recur, and about 20% indicated
that the reported conflict was related to a previous conflict.
Fourth, although data were obtained from 24 countries, the
country distribution was skewed, with Brazil contributing 19%
of ICUs and 21% of respondents, whereas the United States
contributed only 2% of ICUs and 2% of respondents. Neverthe-
less, although the extent to which the participating ICUs and
respondents were representative of their country was unknown,
the response rate in each ICU was 80%. Although the study
cannot be taken as a faithful picture of ICU conflicts worldwide,
the high rate of perceived conflict suggests that conflict in the ICU
may be a universal phenomenon that should be addressed. The
sampling bias suggests that the study may overestimate the
number of conflicts. Efforts to design conflict-prevention strate-
gies that are likely to be effective in many parts of the world may
contribute to improve this perception. Fifth, given the number of
respondents, the high Type I error might influence the final results
for some covariates. Sixth, we did not use the recommended
translation/back-translation method for translating our question-
naires. However, the questionnaires were completed by ICU staff
members, who were more likely to understand our intent than
patients would have been. Last, patients or families were not
surveyed. Previous studies have provided data on conflicts in-
volving patients and their relatives.
In summary, up to 70% of ICU workers reported perceived
conflicts, which were usually considered deleterious and were
significantly associated with reported job strain. Workload, com-
munication, and end-of-life care emerged as potential targets for
improvement. Multifaceted conflict-reducing interventions that
target the well-being of all ICU professionals should be designed
and evaluated.
Conflict of Interest Statement: E.A. received $1,001 to $5,000 from Pfizer France
and $1,001 to $5,000 from Gilead France for serving on an advisory board, and
$10,001 to $50,000 from Pfizer France in industry-sponsored grants for the
Outcomerea Study Group. J-F.T. does not have a financial relationship with
a commercial entity that has an interest in the subject of this manuscript. C.L.S.
received up to $1,000 as a consultant for Eli Lilly & Co., $5,001 to $10,000 from
Novartis Corp for serving on a data steering committee, up to $1,000 from
Hutchinson Technology Incorporated for serving on a safety committee, $5,001
to $10,000 from Artisan Pharma, Inc. for serving on a data monitoring
860 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 180
committee, $5,001 to $10,000 from Eisai Corp for serving on a steering
committee, up to $1,000 from Eli Lilly in lecture fees, $5,001 to $10,000 from
Takeda and $1,001 to $5,000 from Eisai Corp as an investigator in industry-
sponsored grants. M.S. does not have a financial relationship with a commercial
entity that has an interest in the subject of this manuscript. K.R. does not have
a financial relationship with a commercial entity that has an interest in the subject
of this manuscript. A.L. does not have a financial relationship with a commercial
entity that has an interest in the subject of this manuscript. R.A. does not have
a financial relationship with a commercial entity that has an interest in the subject
of this manuscript. M.S. does not have a financial relationship with a commercial
entity that has an interest in the subject of this manuscript. F.R. does not have
a financial relationship with a commercial entity that has an interest in the subject
of this manuscript. B.R. does not have a financial relationship with a commercial
entity that has an interest in the subject of this manuscript. D.B. received $1,001
to $5,000 from Pfizer in lecture fees for a nonpromotional course in medical
statistics and up to $1,000 from GlaxoSmithKline in lecture fees for lectures about
end of life in the intensive care unit. D.H. does not have a financial relationship
with a commercial entity that has an interest in the subject of this manuscript.
G.J. received $1,001 to $5,000 from AstraZeneca Hong Kong, $1,001 to $5,000
from Drager Medical, $1,001 to $5,000 from Fresenius Kabi, $1,001 to $5,000
from Gambro China, and $1,001 to $5,000 from Maquet AB in grants for
educational activity—BASIC course development and delivery. A.F. does not have
a financial relationship with a commercial entity that has an interest in the subject
of this manuscript. P.A-M. does not have a financial relationship with a commer-
cial entity that has an interest in the subject of this manuscript. R.O. received
$1,000 to $2,000 for external lectures from Abbott Laboratories Poland. J.B. does
not have a financial relationship with a commercial entity that has an interest in
the subject of this manuscript. M.D.V. does not have a financial relationship with
a commercial entity that has an interest in the subject of this manuscript. A.V.
does not have a financial relationship with a commercial entity that has an
interest in the subject of this manuscript. A.K. received $1,001 to $5,000 from
Pfizer, $1,001 to $5,000 from Lilly, and up to $1,000 from Fresenius in lecture
fees. S.C. does not have a financial relationship with a commercial entity that has
an interest in the subject of this manuscript. L.K. received up to $1,000 from
Merck, Sharpe, and Dohme in nonpromotional lecture fees. K.H. does not have
a financial relationship with a commercial entity that has an interest in the subject
of this manuscript. F.A. does not have a financial relationship with a commercial
entity that has an interest in the subject of this manuscript. A.K. does not have
a financial relationship with a commercial entity that has an interest in the subject
of this manuscript. H.G. does not have a financial relationship with a commercial
entity that has an interest in the subject of this manuscript. T.K. received $1,001
to $5,000 for lectures on CAP/HAP diagnosis and treatment from Sanofi Aventis,
$5,001 to $10,000 for the Department’s Distinguished Lecturers Program 2007
to 2008, 2008 to 2009 from MSD. A.M. does not have a financial relationship
with a commercial entity that has an interest in the subject of this manuscript.
S.C. does not have a financial relationship with a commercial entity that has an
interest in the subject of this manuscript. B.S. does not have a financial relation-
ship with a commercial entity that has an interest in the subject of this
manuscript.
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